You use or have been advised to use a cane or walker to get around safely.

People who have been advised to use a cane or walker may already be more likely to fall.

Yes (1)

No (0)

Sometimes you feel unsteady when you are walking.

Unsteadiness or needing support while walking are signs of poor balance.

Yes (1)

No (0)

You steady yourself by holding onto furniture when walking at home.

This is also a sign of poor balance.

Yes (1)

No (0)

You are worried about falling.

People who are worried about falling are more likely to fall.

Yes (1)

No (0)

You need to push with your hands to stand up from a chair.

This is a sign of weak leg muscles, a major reason for falling.

Yes (1)

No (0)

You have some trouble stepping up onto a curb.

This is also a sign of weak leg muscles.

Yes (1)

No (0)

You often have to rush to the toilet.

Rushing to the bathroom, especially at night, increases your chance of falling.

Yes (1)

No (0)

You have lost some feeling in your feet.

Numbness in your feet can cause stumbles and lead to falls.

Yes (1)

No (0)

You take medicine that sometimes makes you feel light-headed or more tired than usual.

Side effects from medicines can sometimes increase your chance of falling.

Yes (1)

No (0)

You take medicine to help you sleep or improve your mood.

These medicines can sometimes increase your chance of falling.

Yes (1)

No (0)

You often feel sad or depressed.

Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls.

Total ________

Add up the number of points for each “yes” answer. If the individual scored 4 points or more, they may be at risk for falling. Discuss this brochure with their doctor.

This checklist was adapted from the Greater Los Angeles VA Geriatric Research Education Clinical Center and affiliates and is a validated fall risk self-assessment tool (Rubenstein et al. J Safety Res; 2011:42(6)493-499). Adapted with permission of the authors. Also available on the CDC website.